For each item write in the box the
number that best characterises the patient
during the past week

1 -
ANXIOUS MOOD This item covers the emotional condition of
uncertainty about the future, ranging from worry,
insecurity, irritability and apprehension to overpowering
dread.

0

Absent.

1

Doubtful
whether the patient is more insecure or irritable than
usual.

2

The patient
is clearly in a state of anxiety, apprehension or
irritability, which he may find difficult to control.
However, the worrying still is about minor matters and thus
without influence on the patient's daily life.

3

At times the
anxiety or insecurity is more difficult to control because
the worrying is about major injuries or harms which might
occur in the future. Has occasionally interfered with the
patient's daily life.

4

The feeling
of dread is present so often that it markedly interferes
with the patient's daily life.

Patient is
clearly unable to relax and is full of inner unrest, which
he finds difficult to control, but it is still without
influence on the patient's daily life.

3

The inner
unrest and nervousness is so intense or frequent that it
occasionally interferes with the patient's daily
work.

4

Tensions and
unrest interfere with the patient's life and work at all
times.

3 - FEARS
This item includes fear of being in a crowd, of animals,
of being in public places, of being alone, of traffic, of
strangers, of dark etc. It is important to note whether
there has been more phobic anxiety during the present
episode than usual.

0

Absent.

1

Doubtful
whether present.

2

The patient
experiences phobic anxiety but is able to fight
it.

3

It is
difficult to fight or overcome the phobic anxiety, which
thus to some extent interferes with the patient's daily life
and work.

4

The phobic
anxiety clearly interferes with the patient's daily life and
work.

4 -
INSOMNIA This item covers the patient's subjective
experience of sleep duration and sleep depth during the
three preceding nights. Note: Administration of hypnotics or
sedatives is disregarded

0

Usual sleep
duration and sleep depth

1

Sleep
duration is possibly or slightly reduced (e.g. due to
difficulties falling asleep), but no change in sleep
depth.

2

Sleep depth
is also reduced, sleep being more superficial. Sleep as a
whole is somewhat disturbed.

3

Sleep
duration and sleep depth is markedly changed. Sleep periods
total only a few hours per 24 hours.

4

Sleep depth
is so shallow that the patient speaks of short periods of
slumber or dozing, but no real sleep.